Nursing Care Home Health

The agency failed to ensure the nurse did not remove the adaptic dressing which was ordered to remain in place during wound care for 1 (Patient #1) of 5 sampled patients reviewed for wound care per physician orders.

The agency failed to: 1) Ensure the nurse changed her gloves during wound care per agency’s Policy and Procedures for 1 of 1 patients observed for wound care (Patient #1); 2) Ensure the nurse changed her gloves between patient contact and touching other surfaces for 1 of 1 patients observed for…

The agency failed to: 1. Notify Patient #4’s Physician of the assessment of a new wound for 1 of 4 sampled patients (Patient #4); and 2. Ensure Patient #4’s Physician had received notification of increased pain and ensure follow-up was received for 1 of 4 sampled patients (Patient #4) reviewed for…

The agency failed to clarify Patient #4’s wound care orders, which contained a solution the patient was allergic to, prior to the caregiver administering the treatment for 1 of 4 sampled patients (Patient #4) reviewed for wound care in a total sample of 9. Findings: Review of Patient #4’s Hospital…

The agency failed to: Ensure patients with physician’s orders for Home Health Aide (HHA) received HHA services as ordered for 2 of 2 sampled patients (Patient #7 and Patient #8); andEnsure a patient with orders for the Medical Social Worker (MSW) received MSW services as ordered for 1 of 4 sampled…

The agency failed to ensure a registered nurse (RN) assessed a wound after a change in wound status prior to delegating wound care to the licensed practical nurse (LPN) for 1 of 4 sampled patients (Patient #4) reviewed for wound care in a total sample of 9. Findings: Review of the State Board of…

The HHA failed to ensure its EP communication plan included the names and contact information for the patients' physicians as evidenced by failure to have documented evidence of the patients' physician name and contact information included in its communication plan.

The HHA failed to ensure its EP communication plan included a method for sharing information and medical documentation for patients under their care with other health providers to maintain continuity of care, in the event of an evacuation a means to release permitted patient information, and a…

The HHA failed to ensure its EP communication plan included a means of providing information about the agency's occupancy, needs, and its ability to provide assistance to the authority having jurisdiction, the Incident Command center, or its designee as evidenced by failure to have this information…

The HHA failed to ensure it followed accepted standards of practice as evidenced by failure to include all questions required by the OPH on its TB questionnaire or had documentation of a negative TB test result for 3 (S3RN, S4LPN, S10LCSW) of 7 (S1ED, S3RN, S4LPN, S7OT, S8A, S9ST, S10LCSW)…

The HHA failed to ensure the aide was evaluated for competency by a RN as evidenced by S8A providing direct patient care based on a competency evaluation by a peer rather a RN for 1 (S8A) of 1 aide employed by the agency.

The HHA failed to ensure the home health aide received at least 12 hours of in-service training during each 12-month period as evidenced by failure to have documented evidence that such training had been conducted for the first 5 months of 2019 for 1 (S8A) of 1 aide employed by the agency.

The HHA failed to ensure the physician was alerted to changes in the patient's condition or needs that suggest that the plan of care should be altered as evidenced by failure to follow up with a physician request for PT services for 1 (#5) of 7 (#1 - #7) patient records reviewed for physician…

The HHA failed to ensure there was ongoing interdisciplinary assessment of each patient as evidenced by failure to have documented evidence of periodic discussions among the team regarding the patient's health status and recommendations for the plan of care for 2 (#1, #6) of 7 (#1 - #7) patient…

The HHA failed to ensure services ordered by the physician were provided as indicated in the plan of care as evidenced by failure to have OT services provided as ordered for 2 (#1, #7) of 7 (#1 - #7) of 7 patient records reviewed for OT services from a sample of 7 patients.

The HHA failed to ensure each patient's medical record contained the services/interventions provided and the patient's response to the interventions as evidenced by failure to have documented evidence of assessments and patient response to interventions for 4 (#1, #2, #6, #7) of 7 patient records…